Quality indicators in intensive care medicine for Germany – third edition 2017

Quality improvement in medicine is depending on measurement of relevant quality indicators. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2013 underwent a scheduled evaluation after three years. There were major changes in several indicators but also some indicators were changed only minimally. The focus on treatment processes like ward rounds, management of analgesia and sedation, mechanical ventilation and weaning, as well as the number of 10 indicators were not changed. Most topics remained except for early mobilization which was introduced instead of hypothermia following resuscitation. Infection prevention was added as an outcome indicator. These quality indicators are used in the peer review in intensive care, a method endorsed by the DIVI. A validity period of three years is planned for the quality indicators.

Ward round: Interprofessional and -depending on the treatment spectrum of the intensive care unit -also interdisciplinary case discussion with at least one decision maker (chief physician, head of the intensive care unit) present. The ward rounds should enable all participating professions to provide and receive information regarding the patient's clinical picture. Interruptions of rounds and thus interruptions of this flow of information should be minimized as far as possible.
Daily goals: The daily goals should be defined during the round, taking into account all professions and disciplines involved.
The following points may be focused on when defining daily goals: • Coordinating communication (consultations / relatives / others persons taking part in treatment) • Therapeutic goals/change in therapeutic goals • Targets for analgesia, sedation and delir management • Ventilation/weaning/respiratory therapy • Circulation/fluid homeostasis • Nutrition • Infection management • need for catheters and other invasive procedures • Definition of prevention measures (anticoagulation / decubitus / gastric protection / mobilization / special physiotherapy measures) • Planned measures (diagnostic / therapeutic) • Agreement over medication Documentation: The more professions or disciplines are involved in the treatment of a patient, the more difficult it is to unite participants synchronously to a visit. Therefore, written specifications are of utmost importance in order to guarantee the flow of information. Written documentation to show what has been defined by whose participation helps those who have primarily not attended the round, to comprehend what was considered important. Changes in therapeutic goals can easier be followed. The communication-enhancing effect of a multiprofessional and interdisciplinary round can be supported by special document templates that can be inserted into the daily documentation sheets. Daily goal checklists support the implementation of daily goals as has been shown in the literature. However, checklists alone do not improve patient safety. Improving communication and dissemination of information in intensive care units is a complex challenge for all involved in the ICU. Awareness for this problem should be cultivated.

Dimension Risk and effectiveness Justification
Patient-adapted ventilation strategies were able to reduce ventilatorassociated injury and improve outcome of mechanically ventilated patients. A standardized concept for ventilation therapy is useful and should be maintained. In severe pulmonary failure and the failure of maximum conservative treatment measures (prone position, muscle relaxation, lung recruitment maneuvers), it may be necessary to contact a specialized treatment center to establish an extracorporeal lung assist. Formula ℎ ℎ × 100 Population All mechanically ventilated patients All days of mechanical ventilation over total treatment period Explanation of terminology Evident ventilation goals are ventilation with low tidal volumes and low peak pressure: 1. With controlled ventilation: 6 ml / kg predicted body ideal weight (this is not applicable for assisted ventilation modes) 2. Recommended PEEP setting in relation to FiO2 FiO2 Up to 0.4 0.4-0.5 0.5-0.6 0.6-0.7 0.7-0.8 0.

Dimension Risk and effectiveness Justification
Invasive ventilation is associated with the risk of ventilator-associated pneumonia (VAP) and other possible complications. Therapeutic goal is therefore to start efforts to discontinue mechanical ventilation as soon as possible (so called "weaning") if disease severity allows this. Depending on the type and severity of the disease, it should also be examined whether invasive ventilation can be completely avoided by the appropriate application of non-invasive ventilation (NIV) or by the application of oxygen via high-flow nasal canula (HFNC) or if reintubation after primary successful extubation can be prevented. Formula ℎ otal time of all mechanical ventilation days × 100 Population All patients with mechanical ventilation All days of mechanical ventilation over total treatment period Explanation of terminology Weaning protocol / concept in combination with sedation targets: For every ventilated patient, the potential for weaning should be evaluated daily or a weaning trial should be carried out. The use of standardized weaning protocols can improve the results. There is also a close connection with the QI II, which specifies the targets of sedation and the documentation of collected score values. to only one of the mentioned measures. VAP bundles as such are, however, well-suited to reduce the incidence of VAP. It is recommended to have at least three measures of a VAP bundle present in the SOPs of the intensive care unit, e.g.: Oral Care Avoidance of pulmonary aspiration e.g. by cuff pressure measurements, subglottic secretion suction or oral antiseptic solutions. There are conflicting data on safety regarding the use of oral chlorhexidine. The use of antibiotics for selective oral decontamination (SOD) and selective digestive decontamination (SDD) should prompt to evaluate local data on bacterial resistance.

Possible measures for CLABSI prophylaxis
It is recommended to define a standard procedure for the insertion and maintenance of intravascular catheters and to train its use.

Dimension Risk and effectiveness Justification
Early, adequate and effective infection diagnosis and anti-infective therapy as well as the effective prevention of bacterial resistance are of paramount importance in the management of infections in the intensive care unit. The following principles should be followed: 1. Early and adequate, calculated antibiotic therapy in patients with severe infections and organ failure (sepsis and septic shock). In patients with low disease severity differentiated diagnostic measures and targeted therapy. 2. Adequate microbiological testing before the start of antibiotic therapy 3. Measures to avoid unnecessary anti-infective treatment In addition to source control, qualitatively and quantitatively adequate microbiological testing and adequate anti-infective therapy is crucial for the survival of critically ill patients with severe infections.

Early Enteral Nutrition
Dimension Risk and effectiveness Justification The early start of enteral nutrition (EN) within the first 48 hours is associated with a reduction of infectious complications and a lower mortality rate of intensive care patients. There is sufficient consensus in the ASPEN recommendation on the appropriate calorie quantity. The definition of a calorie goal is strongly recommended. Parenteral nutrition as a supplement can be useful to achieve the desired calorie goal. Formula * number of patients that can be fed enterally × 100 (* At least 50% of the daily recommended calorie intake) Population All patients in the intensive care unit Explanation of terminology Indication for EN: All patients without contraindication for enteral nutrition, who do not tolerate a complete oral diet. The calorie goal is based on age, body weight and nutritional status of the patient. The current practice guidelines show no consensus on the appropriate amount of energy . At least 50% of the daily nutrition requirement should be reached within 48 hours. Nutritional therapy should be done according to a standard. An early enteral diet avoids a calorie deficit in the patient, which has a negative effect causing increased infection rates and an extended length of stay. It is recommended to use nutritional protocols to establish early enteral feeding. Supplementary parenteral nutrition can close the gap between the patient's calorie requirements and the enterally supplied energy. The enteral and metabolic tolerance of the patient should be taken into account. The European guidelines recommend an additional parenteral diet if the calorie target cannot be achieved by enteral nutrition after 3 days. They define about 25 kcal / kg / d as the calorie target. A strict adjustment of the blood sugar can no longer be generally recommended. New investigations favor an upper limit of blood glucose levels of 10mmol / l or 180 mg / dl.

Dimension Risk and effectiveness Justification
The determination of the patient's preferences is of utmost importance in the planning and implementation of intensive care treatment. Only the interplay of correct medical indications and the determined patient's preferences leads to appropriate therapy decisions and avoids conflicts with patients and family members. The communication of therapeutic goals between intensive care personnel and patients and relatives helps building trust but also reduces grief and grief-induced morbidity (depression, PTSD) in patients and their families. It also serves to prevent staff morbidity. In order to make communication results sustainable, their documentation is mandatory. For the coping with the critical illness of a family member the use of a patient diary can be helpful. Quastionnaires for patient and / or family satisfaction help adjust these communication processes if necessary. Formula Appropriately documented communications Documented communications × 100 Population All patients in an intensive care unit after a critical event Explanation of terminology Documentation of family discussions of patients after a critical event in an intensive care unit. A critical event is an emergency or the unplanned admission or a sudden change in the patients condition. Within 48 hours after the event and furthermore at least once a week, a communication should be documented whose content meets the following requirements: 1. Explanation of the patient's current status 2. Current treatment plan 3. Determination of the patient's wishes either through the patient himself or through his relatives. Determination of the perspective of the family, provided the patient can not speak freely for himself. 4. To what extent can patient preferences and therapeutic goals be brought into concordance? 5. Indication of short-term, medium-term targets / prognosis determined by the treatment team 6. Conclusion / Definitions / Consequences A detailed presentation of aspects of these discussions is given in the position papers of the DIVI from 2006 and 2012. Each discussion should be documented with the names of the participants (including representatives of the interprofessional treatment team) and date.